Slow progress, long way ahead for cultural safety in kidney care

A review of over three decades of research into kidney care in First Nations communities has revealed significant ongoing challenges in achieving cultural safety. Despite progress, experts argue there is still much work to be done to ensure that care is not only clinically effective but also culturally responsive and respectful.

The review, led by University of Adelaide Nursing School Senior Lecturer Melissa Arnold-Ujvari, Senior Research Fellow Elizabeth Rix, and Professor Janet Kelly, was published in Nursing Inquiry. The study examines the evolution of kidney care literature and highlights the continuing barriers to cultural safety in healthcare settings.

"Thirty years ago, kidney care literature was solely focused on biomedicine, with culture, family, and community often seen as barriers to patient compliance with treatment," said Mrs. Arnold-Ujvari. "While the importance of culturally informed care gained recognition in the mid-1990s, it wasn’t until around 2014 that cultural safety specifically began to be addressed in kidney care."

Cultural safety involves understanding that beliefs, values, and attitudes are shaped by a person’s social environment and life experiences. The concept calls on healthcare professionals to critically reflect on their own worldviews and biases, acknowledging that these can influence their clinical practices. Achieving cultural safety also requires building trust and understanding through empathetic, respectful relationships and continuous learning.

“The responsibility for cultural safety falls not only on the individual health professional but also on health institutions and services,” Mrs. Arnold-Ujvari noted. "Healthcare providers must reflect on their practices and remain open to feedback from patients and communities. Ultimately, it is the recipient of care who determines whether care is culturally safe or unsafe."

The review found that while awareness of cultural safety has grown over the years, significant gaps remain. Since 2000, kidney health research has increasingly emphasized the need for effective communication and the importance of involving community reference groups, Elders, and Indigenous health workers in shaping care models. However, miscommunication between healthcare providers and Indigenous patients remains a major issue.

In 2002, Indigenous patients identified pervasive miscommunication as a barrier to effective dialysis and kidney care. Many noted that healthcare staff required training in intercultural communication to bridge these gaps.

“For the kidney care workforce, culturally safe care requires not just critical self-reflection, but also deep active listening, decolonising approaches, and an ongoing commitment to eradicating institutional racism,” Mrs. Arnold-Ujvari said. “Until we listen actively to patients, incorporate their needs, and involve them in decision-making, we cannot be certain that we are providing culturally safe and responsive care.”

The review was partly informed by an extensive literature search for the inaugural Caring for Australians with Renal Insufficiency (CARI) guidelines. These guidelines highlight addressing institutional racism as a top priority and recommend dialysis treatment on Country and expanding the Indigenous workforce in kidney care.

"The next major challenge is ensuring that all healthcare staff working in kidney care adhere to these guidelines," said Mrs. Arnold-Ujvari. "Following that, we must develop a reliable way to evaluate cultural safety from the perspective of Indigenous patients."

By fostering cultural safety, healthcare professionals can reduce individual-level racism, but to address institutional racism, systemic change is necessary. "For institutional racism to be eradicated, healthcare institutions must fully commit to cultural safety and build accountability for it at the organizational level," Mrs. Arnold-Ujvari concluded.